New York University
Federal Credit Union
PH: 212-995-3166
Fax: 212-995-4582
14 Washington Place,
New York, NY 1003-6696
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INDIVIDUAL FINANCIAL STATEMENT
Financial condition as of ______/______/_______
APPLICANT INFORMATION
Complete this form for (1) each proprietor, (2) each limited partner who owns 20% of more interest and each general partner, or (3) each stockholder
owning 20% or more of voting stock, or (4) any person or entity providing a guaranty on the loan.
Applicant Name
SSN
Business Name (if applicable)
Phone Number
H
W
Cell
Home Address
If assets are owned jointly with spouse, please provide name of spouse:
BALANCE SHEET INFORMATION
ASSETS
LIABILITIES
Cash in hand and in Banks
$
Accounts Payable
$
Savings Accounts
$
$
IRA of Other Retirement Account
$
Accounts & Notes Receivable
$
Cash Value of Life Insurance
(Describe in Section 8)
Stocks & Bonds
(Describe in Section 3)
Real Estate
(Describe in Section 4)
Automobile(s) – Present Value
$
Notes Payable to Banks & Others
(Describe in Section 2)
Installment Account (Auto)
Monthly payments: $___________
Installment Account (Other)
Monthly payments: $___________
Loan on Life Insurance
Mortgages on Real Estate
(Describe in Section 4)
Unpaid Taxes
(Describe in Section 6)
Other Liabilities
(Describe in Section 7)
$
Other Assets
(Describe in Section 5)
Total Assets
$
Total Liabilities
$
Net Worth (Difference between total assets
and total liabilities)
$
$
$
$
$
Section 1: SOURCE OF INCOME**
$
$
$
$
$
CONTINGENT LIABILITIES
Salary
$
As Endorser or Co-Maker
$
Net Investment Income
$
Legal Claims & Judgments
$
Real Estate Rental Income
$
Provision for Federal Income Tax
$
Other Income (Describe below)
$
Other Special Debt (Describe below)
$
Description of Other Income/Debt in Section 1:
**Alimony or child support payments need not be disclosed in “Other Income” unless it is desired to have such payments counted toward total income.
Name/Address of Noteholder(s)
Section 2: NOTES PAYABLE TO BANK AND OTHERS
Original Balance
Current Balance
Payment Amount
How Secured – Type of Collateral
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Section 3: STOCKS AND BONDS
Number of Shares
Name of Securities
Cost
Market Value
Quotation/Exchange
Date of
Quotation/Exchange
Total Value
Section 4: REAL ESTATE OWNED
Property A
Property B
Property C
Type of Property
Address
Date Purchased
Original Cost
Present Market Value
Name/Address of Mortgage Holder
Mortgage Account Number
Mortgage Balance
Payment Amount per Month
Section 5: OTHER PERSONAL PROPERTY AND OTHER ASSETS
(Describe, and if any is pledged as security, state name and address of lien holder, amount of lien, terms of payment, and delinquency, if applicable)
Section 6: UNPAID TAXES
(Describe in detail as to type, to whom payable, when due, amount, and to what property, if any, a tax lien attaches.)
Section 7: OTHER LIABILITIES
(Describe in detail)
Section 8: LIFE INSURANCE HELD
(Give face amount and cash surrender value of policies, name of insurance company and beneficiaries)
I authorize New York University Federal Credit Union to make inquiries as necessary to verify the accuracy of the statements made and to determine by creditworthiness.
I certify that the above and the statements contained in the attachments are true and accurate as of the stated date(s). These statements are made for the purpose of
either obtaining a loan or guaranteeing a loan. I understand that false statements may result in forfeiture of benefits and possible prosecution by the U.S. Attorney
General (Reference 18 U.S.C. 1001).
Signature:
Date:
Social Security Number:
Signature:
Date:
Social Security Number: